Provider Demographics
NPI:1790912806
Name:TIDWELL, KATRINA JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:JEAN
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8196 WALNUT HILL LN
Mailing Address - Street 2:STE 100
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4452
Mailing Address - Country:US
Mailing Address - Phone:214-739-4175
Mailing Address - Fax:214-346-3516
Practice Address - Street 1:8196 WALNUT HILL LN
Practice Address - Street 2:STE 100
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4452
Practice Address - Country:US
Practice Address - Phone:214-739-4175
Practice Address - Fax:214-346-3516
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03458363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
8L22066Medicare PIN